Discovering CAH

Operational Improvements

Margaret Brockman, RN, MSN

Director Nebraska Office of Rural Health

June 24, 2015

Learning Objectives

• Hear the stories of state Flex Programs who

have successfully partnered with CAHs on

operational improvement initiatives

• Establish pathways for partnering with

CAHs on performance excellence initiative

through Flex

Where to Start?

What are we trying to improve and why?

Reduce the

COST of

Care!

Improve

Reliability

& SAFETY

Increase the

QUALITY of

Care!

Why a Lean Culture for Rural Hospitals?

Because in Rural Hospitals, we can lead in:

• Quality of Care and Patient Safety

• High Value Customer Service

• Cost Effectiveness and Efficiency

What is Lean?

• An organizational culture characterized by

the endless pursuit of the elimination of

waste.

• An effective methodology for improving

patient safety, quality and cost while

preventing delays, bridging “silos” and

improving employee satisfaction.

Why Lean?

“It provides a way to do more with less – less

human effort, less equipment, less time and

less space – while coming closer and closer to

providing customers with exactly what they

want.”

– James Womack

Author, “Lean Thinking” 1996

Lean Success is…

…Not found in the tools, it’s the culture!

Ultimate Goal is building the culture

To Establish a Lean Culture:

• Looking for opportunities

• Establish systems

• Recognize and eliminate constraints

• Managers and Directors learn to help their staff

Hospital Goals

• Patient Safety

• Patient Satisfaction

• Employee, Staff Satisfaction

• Employee Engagement

• Low Turnover

• Productivity

• Space Utilization

We don’t have time for one more thing!

• What if I told you that 35 to 40 percent of

what you are doing now doesn’t add value

to your patients!

Lean Thinking Principles for Healthcare

Principle Lean Hospitals Must:

Value Specify value from the standpoint of the end customer (the

patient).

Value Stream Identify all the value-added steps across department

boundaries (the value stream), eliminating steps that do not

create value.

Flow Keep the process flowing smoothly be eliminating causes of

delay, such as batches and quality problems.

Pull Avoid pushing work on the next process or department; let

work and supplies be pulled, as needed.

Perfection Pursue perfection through continuous improvement

Do we really have waste in healthcare?

Anything that adds cost or time without

adding value as defined by the primary

customer is waste.

The 8 Deadly Wastes

Transportation

Inventory

Motion

Waiting

Overproduction

Over-Processing

Defects

Unused Talent

“That’s just the way

work is done

around here.”

Waste

becomes

accepted

Nebraska CAH Lean Collaborative

Mission:

To develop an active partnership model spreading

lean culture transformation across rural healthcare

organizations in Nebraska.

Goal:

To achieve successful lean culture transformations

in early adopting CAHs and to be recognized

nationally

Nebraska CAH Lean Collaborative

• Utilized FLEX funding (However, ROI is clearly advantageous)

• Technical Assistance Available

• Provided Lean tools and Resources

• Collaboration between facilities – sharing of

ideas and best practices

The Journey…

2011

• Contracting with Midwest Health Consultants (MWHC) to

work with 10 CAHs (2 pilot groups).

• Utilized 10 hospitals within one of the networks

• Each hospital formed an internal, multidisciplinary team to

learn and apply the concepts of Lean to a performance

improvement issue.

• Each hospital implemented at least one Lean project.

Nebraska CAH Lean Collaborative

Phase 1:

A Pilot a Rural Hospital Lean Transformation

Collaborative engaging five rural hospitals in CAH Link:

• Jefferson Community Health Center

• Fillmore County Hospital

• St. Mary’s Hospital

• Avera St. Anthony Hospital

• Thayer County Hospital

Nebraska CAH Lean Collaborative

Phase II:

• Box Butte General Hospital

• Nemaha County Hospital

• Chase County Hospital

• Tri-Valley Health System

• Brown County Hospital

• Brodstone Memorial Hospital

Six Sigma Greenbelt

Certification Program• 4 day course

• 30 hrs. classroom instruction

• 30 hrs. practical experience

• Pass the final exam

• Complete a Lean project over the next 120 days

• Focus on improving efficiency by lowering costs

• Improving quality

• Increase patient and/or employee satisfaction

Results

• Year 1 Total savings of $445,685 in either increased revenue or

decreased cost to the hospital.

• Year 2 $264,109 savings

Non-economic projects resulted in 15% reduction in one of the quality indicators

Total in 2 yrs. • Over 30 CAHs

• More that 100 people trained

• Approximately $710,000 saved

Lessons Learned…

• Lean can provide the significant positive results, but it is

not easy or a quick fix.

• Lean must also be implemented correctly, consistently, and

be given sufficient time.

• Everyone in the organization must commit to becoming

Lean and it requires both cultural change and systems

thinking.

• Not sufficient to train 3-4 people within the hospital to

champion and direct Lean implementation.

Since the Pilots…2013 Established the Nebraska CAH Lean Six Sigma Greenbelt

Certification Process

August

2013

• 22 Students from 8 CAHs in Nebraska

• Two on-site certification completed in two CAHs. 12 participants

in each CAH

January

2014

• Second course offered

• Ten participants from 3 CAHs

March

2014

• Lean Healthcare Yellow Belt training (5-hour course

This course can be taken by the Certified Greenbelts to teach

the principles of Lean Thinking in their facility.

January

2015

• Development of On-line course

Delayed due to formatting

May

2015

• Greenbelt Certification Course

• 4 CAHs, 12 students

Where are we going from here?

Next Phase:

–Website course access

–More Yellow Belt Courses

–Continue Green Belt Instruction

–More on-site training

Flex Grant Goal

• Have 6-8 Greenbelts in each of the 64 CAHs

• 25-50 students in Green belt

– 2 courses/yr.

• 25-50 students in Yellow belt

• 25-50 students to participate online

– Take at their own pace/any time of year

• Present projects at the Annual Nebraska Quality

Improvement Conference

Stories from the Field…

Stories

• A Revenue cycle maximization project led to a reduction in direct labor and

outside consulting costs. This project also reduced days in accounts receivable

by 22% over 90 days.

• A pre-operative patient visit project reduced patient waiting times by 29% and

decreased the total time for a pre-operation evaluation by 22%. The direct

labor cost saved annually was $24,694.

• A respiratory therapy project increased revenue by $63,000, improved nursing

staff satisfaction by 24%, and increased respiratory therapists’ satisfaction by

72%.

• A patient registration improvement project decreased the registration process

by 80% and resulted in over $15,000 in direct labor costs annually.

More Stories

• One facility cut the transportation of inpatients to and from imaging services

by 60 %.

• One facility improved the turnaround time for its top five laboratory tests

ordered by 35%

• Another facility cut the time patients waited in the emergency room to begin

treatment to 28 minutes from 48 minutes

• Two facilities cut the amount of time for discharging a patient (on average) to

45 minutes from 90 minutes. The improvement allowed the hospitals to admit

patients sooner, boosting patient days and increasing net revenue.

• A business office looked at their process for the pre-certification of patients.

They used the Lean tool of value stream mapping to determine the current path

and process for pre-certification. The net result was a 36% decrease in the

number of denials.

More Stories

• A surgical department in one facility changed the process of how surgical kits

were put assembled and improved their gross revenue by $28,000 while at the

same time reducing their expenses by 18%.

• A hospital used the value stream mapping process on how respiratory therapy

patients flowed through the facility from admission to discharge. With

modifications in the process, they identified services that were being given to

patients but were not being charged for. They discovered nearly $13,000 a

month in unbilled services.

More Stories

Organization of storage space using the Lean 5S tool.

Staff members were entering the storeroom at least 5

times per day for an average time of 10 minutes for each

entry or 50 minutes per day at a cost of $23 per hour. The

cost was $6,935 per year. That has now been decreased to

1 minute per entry with a decrease to $695 per year. The

less time the nurses are looking for things, the more time

they can spend with patients. The storeroom also has

more space.

Annual reduction in direct

labor costs:

Square footage gained

(annualized):

Reduction in staff time looking

for needed equipment and

supplies in the hospitals

storage areas.

$ 6,100

$ 4,500

90%

More Stories

Capturing Respiratory Therapy Charges

It was the practice of this facility to have nurses

administer scheduled Respiratory Therapy (RT)

treatments to patients on the weekends. The nurses

also would occasionally ‘fill in’ for RT during the

week when RT was busy. By regulation, a hospital

is not allowed to charge for RT treatments

performed by nursing staff. It appeared that the

revenue lost by nursing administrating RT

treatments over the weekends would support a

FTE in RT. The goal of this project was to

analyze, redesign and improve the current work

process so as to capture that revenue missed by

the nurses treating RT patients on the weekends.

Consequently the RT process change improved

nursing and RT satisfaction rates as well as value

to the patient care plan.

Revenue generated

from this project in

capturing RT treatment

charges in a 3 month

time period:

Improvement of

nursing staff

satisfaction:

Improvement of RT

staff satisfaction:

$63,000

24%

72%

More Stories

Establishment of a Nurse/Patient Server Supply System

Travel time, poor access to needed supplies,

increased cost of maintaining a “central supply”,

poor stocking practices resulting in supplies

being absent when needed. This project has

virtually eliminated these concerns by having

80% of the most frequently used items at the

patient’s bedside vs. a central storage area.

Translated into costs, over the course of a years’

time the dollar amount of this travel time is

significant ($1,709.76) per RN per year. With 15

RN’s on staff that’s $25,646.40 spent on travel

time. In terms of

supply cost, the hospital had found and

destroyed nearly $5,000.00 dollars’ worth of

expired supplies that were “shoved” to the back

of shelving units.

Decreased supply/

inventory costs:

Annualized savings:

Increase in staff

satisfaction:

21%

$40,800

47%

Applications for other FLEX Programs

• Can be utilized in other states utilizing

FLEX funds or SHIP funds

• Start with a group of hospitals

• Find hospitals that want to change their

culture

Questions?

Contact InformationMargaret Brockman

Nebraska Office of Rural Health

Email: Margaret.Brockman@Nebraska.gov

Phone: 402-471-6057